MEDICARE: WOODLAND NURSING INN, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	CA
2	332BN1400X	Nursing Facility Supplies (DME)	CA
3	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	CA
4	314000000X	Skilled Nursing Facility	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1128360001	OTHER	CA	NSC NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629060702
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOODLAND NURSING INN, INC.

Provider Business Mailing Address
First Line	:	3 CROW CANYON CT
Second Line	:
City	:	SAN RAMON
State	:	CA
Zip	:	94583-1966
Country	:	US
Telephone Number	:	925-855-0881
Fax Number	:	925-855-9297

Provider Business Practice Location Address
First Line	:	3721 MT DIABLO BLVD
Second Line	:
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-3538
Country	:	US
Telephone Number	:	925-284-5544
Fax Number	:	925-284-5673

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JEREMY E GRIMES
Credential	:
Telephone Number	:	925-855-0881

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	11/21/2007

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